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Facial Fracture Classification According to Skeletal Support Mechanisms

Facial Fracture Classification According to Skeletal Support Mechanisms

ORIGINAL ARTICLE Facial Fracture Classification According to Skeletal Support Mechanisms

Terry L. Donat, MD; Carmen Endress, MD; Robert H. Mathog, MD

Objective: To construct, propose, and evaluate the use- tures. This scheme was accurately applied and suffi- fulness of a new clinical facial fracture classification cient to describe 87 midfacial fracture patterns in this scheme to accurately denote, communicate, and com- study. In addition, 118 (98%) of 120 mock fracture pat- pare facial fractures. terns were correctly transcribed and reproducibly com- municated among 12 participating physicians. Design: A retrospective, consecutive sample study with application of the proposed classification scheme to de- Conclusions: This newly proposed facial fracture clas- note maxillary and zygomatic fractures with computed sification scheme provides a convenient, specific, de- tomography. scriptive, and reproducible method of denoting fracture patterns. This scheme may be used to accurately com- Setting: Metropolitan tertiary care trauma center. municate and compare, in greater detail than permitted using current independent classification schemes, the es- Patients: A total of 213 consecutive adult patients with sential site and degree-of-severity characteristics of fa- facial fractures evaluated by means of 2-dimensional com- cial fractures critical to their surgical reduction and re- puted tomography. construction. The usefulness of this classification scheme in determining optimal methods and subsequent out- Results: The classification scheme is defined accord- comes in midfacial fracture reduction requires further ing to fractures of vertical buttresses and horizontal beams. investigation. The scheme uses 3 primary descriptors of laterality and support sites to denote the clinical pattern of the frac- Arch Otolaryngol Head Neck Surg. 1998;124:1306-1314

HE INCIDENCE, mecha- tomographic (CT) scanning technology, nisms, and pathophysiol- a major advance over plain x-rays, for ogy of facial fractures are fracture identification and fragment well described in the litera- visualization.17-20 ture, as are the current ap- Despite the widespread acceptance proaches to fracture reduction and fixa- of current diagnostic and treatment T1-5 tion. The 3 goals of therapy in treating methods, the most commonly used clas- midfacial fractures are (1) to restore func- sification for describing facial fractures tional occlusion; (2) to stabilize the ma- remains that classically described by jor facial skeletal supports, thereby restor- French physician Rene LeFort, which ing the premorbid 3-dimensional contour alone yields insufficient information for (height, width, and projection) to the ; fracture description and the complete From the Department of and (3) to provide skeletal support for the planning of treatment. LeFort’s original Otolaryngology–Head and proper and appearance of the classification described “the great lines Neck , University of overlying facial soft structures. of weakness” according to fracture pat- Minnesota Health Sciences The current approach to facial frac- terns he experimentally produced.1 The Center, Minneapolis ture repair requires the repositioning of LeFort classification is inadequate in that (Dr Donat), and Departments the fracture segments into anatomic it does not define the facial skeletal sup- of (Dr Endress) and position, with a focus on the lattice sup- ports or the more severely comminuted, Otolaryngology–Head and ports in relation to each other and to the incomplete, or combination maxillary Neck Surgery (Dr Mathog), cranial .6-10 Modern therapy also Wayne State University, Detroit, Mich. Dr Donat is now mandates the rigid stabilization of the with the Department of vertical and horizontal facial supports to withstand the forces of mastication.11-16 This article is also available on our Otolaryngology–Head and Web site: www.ama-assn.org/oto. Neck Surgery at Wayne State Such treatment plans are made possible University. by the diagnostic capability of computed

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 METHODS Examples shown in Figure 2 through Figure 5 demon- strate the methods.

ANATOMIC CONSIDERATIONS EVALUATION FOR CLASSIFICATION The classification system was evaluated retrospectively by The scheme for the midfacial fracture classification sys- reviewing medical records of 213 adult patients with mid- tem in this study was designed by partitioning the 3 pairs facial fractures treated at Detroit Receiving Hospital, De- of horizontal structural supports (beams) and 3 pairs of troit, Mich, from January 1, 1993, through June 30, 1995. vertical structural supports (buttresses). Based on the All patients were evaluated by axial and coronal CT scan intersection of these supports and segmental divisions, imaging. The patients ranged in age from 18 to 70 years there were 11 unilateral sites and 22 bilateral sites with the primary mechanisms of injury being blunt trauma (Figure 1 and Table 1). The 3 primary, paired horizon- caused by altercation or motor vehicle accident in 208 pa- tal beams from superior to inferior were the superior tients (97.6%) or penetrating trauma caused by gunshot orbital rims combined with the (H1), the inferior wounds in 5 patients (2.4%). Twenty-six patients were orbital rims combined with the zygomatic arches (H2), women and 187 were men. and the alveolar processes of the (H3). The pri- To determine whether the fractures could be ana- mary, paired vertical buttresses from anterior to posterior lyzed and assigned to a specific notation, the CT scans were were the nasal maxillary (V1), the zygomaticomaxillary evaluated for fracture sites and these sites were then dia- (V2), and the pterygomaxillary (V3) buttresses. The grammed and transcribed according to the classification sys- beams were further categorized into central (c) and lateral tem. Evaluations were blinded to any prior medical rec- (l) segments, and the buttresses were categorized into ords or radiology interpretation. Designations were then superior (s) and inferior (i) segments. Nasal fractures, related to a standard method of description to show the thin lamina fractures (such as found along the orbital advantages and disadvantages of the system. walls and the walls of the maxilla), and the degree of frac- To whether the notations could serve as an effi- ture displacement were not included as part of the classifi- cient and valid means of communication, 12 resident phy- cation system. The classic completed LeFort and zygo- sicians were presented with a series of mock facial frac- matic fracture patterns as herein represented according to ture diagrams and fracture designations. Each physician was buttress and beam support involvement are listed in presented first with 5 distinct fracture patterns dia- Table 2. grammed according to the classification scheme and asked Individual fracture locations were denoted laterally (left to provide notations of the fracture patterns; they were or right), by involvement of the fractured buttress or beam subsequently presented with 5 new distinct notations of (vertical or horizontal), and at the site of the fracture line fractures and asked to diagram the fracture pattern repre- along the buttress, superior or inferior, or along the beam, sented by the notation. The number of the correctly tran- central or lateral. The fractures of patients were denoted scribed fracture diagrams and notations was determined. by listing in sequence the location of individual fractures. Transcription errors were also determined.

fractures. Moreover, it does not describe the fractures of nasal alone and were not included for analysis. The the part bearing the occlusal segment.4 The LeFort clas- remaining 170 cases were classified and are listed in sification thus often underestimates the complexity of Table 3. Cases were described according to whether the the fractures and limits the complete description of the injury was unilateral left (L), unilateral right (R), or bi- overall facial fracture pattern, which often includes any lateral, and were compared with prior nomenclature sys- array of fronto-orbital, zygomatic, and nasoethmoidal tems, where applicable. fractures in combination with maxillary injury. The classification scheme was easily applied to all The goals of a classification system oriented to- of the fracture patterns determined by axial and coronal ward current therapy for midfacial fractures should ide- CT scan for the patients in this study. No fracture pat- ally include information obtained from the clinical, sur- terns in this study were deemed unassignable, as might gical, and CT radiological examinations (1) to accurately occur due to a fracture line passing through a buttress/ represent the anatomic and functional magnitude and beam intersection. Using the proposed classification, 40 complexity of the overall midfacial fracture pattern, differing unilateral fracture patterns were identified (2) to describe the involved functional skeletal sup- among 122 patients who presented with unilateral fa- ports critical to the proper design for surgical therapy, cial fractures. Forty-seven differing fracture patterns (3) to provide a meaningful common terminology for were identified among the 48 patients presenting with communication of the fracture information between bilateral facial fractures. Therefore, using the proposed the radiologist and surgeon, and (4) to provide spe- classification, 87 specific and distinct fracture patterns cific information sufficient for comparison of treat- were described among the 170 patient CT scan studies. ment outcomes of midfacial fracture treatments. Only 25 (28.7%) fracture patterns reviewed met the defined criteria of LeFort fractures in which they RESULTS had all of the fractures required for 1 of the classic LeFort fracture patterns. Among these, only 11 could be Among the 213 patients, 43 cases involved fractures of identified as bilateral LeFort fractures of the same level, the bony lamina of the orbital walls (blowout type) or although often with considerable variation in complex-

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Table 2. Facial Beam and Buttress Involvement in Classically Defined* Complete Maxillary and Zygomatic Fractures

Right Left Fracture Pattern Proposed Designation Midline LeFort I* (Guerin) L V1i, V2i, V3 H1 H1c R V1i, V2i, V3 LeFort Il* L V1s, V2i, V3, H2 R V1s, V2i, V3, H2 V1s LeFort IlI* L V1s, V2s, V3, H2l V2s R V1s, V2s, V3, H2l Zygomatic (tripod) V2s, V2i, H2, H2l H2l H2 *The classic fracture descriptions by LeFort and Guerin1 mandated the bilateral involvement of the pterygoid plates for a complete fracture. V1iV3 V2i Fractures without bilateral involvement of the pterygoid plates or other defined “lines of weakness” were classically described by LeFort as incomplete, unilaterally outlined, or unilaterally indicated. L indicates left; R, right. See legend to Figure 1 and Table 1 for an explanation of the H3 H3c abbreviations.

Right Left Midline Figure 1. Designations of fractures according to horizontal beams and H1 H1c vertical buttresses. Beams: superior orbital rims and glabella, H1; inferior orbital rims and zygomatic arches, H2; of maxilla, H3; c indicates central; l, lateral. Buttresses: frontonasomaxillary, V1; V1s frontozygomaticomaxillary, V2; pterygomaxillary, V3; s indicates superior; i, V2s inferior. Reprinted with permission from illustrator William Loechel.

H2l H2 Table 1. Designation of Buttress and Beam Segments V1iV3 V2i

Abbreviation Description Buttress V1 superior V1s Nasofrontal buttress (glabella to H3 H3c nasomaxillary ) V1 inferior V1i Nasomaxillary buttress (nasomaxillary suture to alveolus) V2 superior V2s Zygomaticofrontal buttress (malar eminence to frontal ) V2 inferior V2i Zygomaticomaxillary buttress (malar eminence to alveolus) V3 V3 Pterygomaxillary buttress Beam Figure 2. Designations of fractures in case 1. Left: V1i, V2i, H2; right: V1i, H1 H1 Supraorbital rims V2s, V2i, H2, H2 l. See legend to Figure 1 and Table 1 for an explanation of H1 central H1c Intraorbital (glabellar the abbreviations. Reprinted with permission from illustrator William frontal bone) Loechel. H2 H2 Infraorbital rim (malar eminence to nasomaxillary suture) H2 lateral H2l The mock facial fracture patterns presented to the H3 H3 Maxillary alveolus 10 participating physicians for transcription are listed H3 central H3c Premaxillary alveolus in Table 4, with the first 5 having been transcribed from a classification diagram to the fracture pattern notation and the subsequent 5 having been transcribed ity between sides. Most illustrative of the complexity of from the pattern notation to a classification diagram. the fractures in this series is that current classifications, Of the 120 total patterns posed for evaluation, only 2 if applicable at all, do not describe the multitude of dis- were miscommunicated, each by different physicians. tinct fracture patterns, as have herein been identified by The 2 errors that occurred were an incorrectly dia- the involved facial supports. The specific information grammed template for laterality (right and left inter- critical to the modern approach and method of treat- posed, mock facial fracture pattern 5) in 1 pattern and ment is therefore seen to be deficient in currently used an incorrectly diagrammed buttress designation (V1i classifications of midfacial fracture patterns. and V2i interposed, mock facial fracture pattern 9) in

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D E F

Figure 3. Case 1. Computed tomographic (CT) scans of a 28-year-old man who received multiple manual facial assault impacts. A, Coronal CT scan displaying fractures left V1i, H2, and right V2i. B, Coronal CT scan displaying fractures left V1i, H2, V2i, and right V1i, V2s, V2i, H2. C, Coronal CT scan displaying fractures left V1i, H2, V2i, and right V1i, V2s, V2i, H2. D, Axial CT scan displaying fracture left V2s. E, Axial CT scan displaying fracture H2 l. F, Coronal CT scan displaying intact V3. See legend to Figure 1 and Table 1 for an explanation of the abbreviations.

COMMENT

Recent technological advances in radiologic imaging have been beneficial in the overall approach to the diagnosis

Right Left and treatment of facial fractures. The widespread ad- Midline vent of CT scanning in the United States in the past de- cade markedly improved the accuracy of fracture imag- H1 H1c ing to greater than 95%, subsequently enabling the treating surgeon to better determine the requirements for sur- gery and a plan for approaches and methods of re- V1s V2s pair.17-21 In addition, the recent advances in both the ar-

H2l eas of internal rigid fixation and the use of autogenous H2 bone grafts for reconstruction have yielded an im- proved early treatment of fractures with the reestablish- V1i V3 V2i ment of anatomic form and function before the onset of the sequelae previously seen with tech- niques, poor fracture exposure, and stabilization, or a de- 7,16 H3 H3c lay in fracture treatment. It is in accordance with these diagnostic and treatment advances that the need for a clas- sification system providing a means for the informative description and communication of facial fractures char- acteristics, especially between the radiologist and sur- geon, has become obvious. The LeFort classification system, albeit quite simple and used for many years, does not amply Figure 4. Designation of fractures in case 2. Left: V1s, V1i, V2s, V2i, V3, describe multiple sites of fracture now seen with mod- H1c, H2, H2 l, H3c; right: V1s, V1i, V2s, V2i, V3, H1, H1c, H2, H2 l. See ern imaging techniques. In an attempt to improve inter- legend to Figure 1 and Table 1 for an explanation of the abbreviations. pretations of these images and applications of treat- Reprinted with permission from illustrator William Loechel. ment, Manson et al6 described a method that looked at displacement and forces to create the fracture and noted the other pattern. No errors occurred in providing the the contribution of supporting vertical buttresses of the mock fracture pattern notation from the mock fracture face especially for application and understanding of the classification diagrams. role for . Approach algorithms were

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D E F

G

Figure 5. Case 2. Computed tomographic (CT) scans of a 23-year-old male driver who received a high-velocity facial impact from an automobile tire jettisoned from a truck traveling ahead of the patient’s vehicle. A, Coronal CT scan displaying fractures left H1c and right H1, H1c. B, Coronal CT scan displaying fractures left V1s, H1c, and right V1s, H1c. C, Coronal CT scan displaying fractures left V1s, V2s, H2, and right V1s, V2s, H2. D, Coronal CT scan displaying fractures left V1i, V2i, V3, H2 l, H3c, and right V1i, V2i, H2 l. E, Axial CT scan displaying fractures left V1i, V2i, H2 l, and right V1i, V2i, H2 l. F, Axial CT scan additionally displaying fractures left V3 and right V3. G, Axial CT scan displaying fractures left V1s, V2s, and right V1s, V2s. See legend to Figure 1 and Table 1 for an explanation of the abbreviations.

offered by Gruss et al,7,8 using central and lateral midfa- ers such as the presence or absence of fractures of the cial fracture descriptions, as well as Gruss et al stressing nasal bones, fractures of orbital lamina, and fractures the importance of the zygomatic arch in guiding the with displacement and/or comminution can be added to reestablishment of facial skeletal contours. Other classi- provide a comprehensive description of the injury. fications were described to supplement the LeFort These concepts thereby allow for an increased specific- description and were based on detailed descriptions of ity of information in describing the variations in frac- fractures of individual midfacial regions, such as orbito- ture patterns that may occur in patients with midfacial zygomatic fractures classified by Zingg et al,12 and the fractures that is not currently possible using other clas- nasoethmoid classification by Leipzinger and Manson.13 sification schemes. Our system emphasizes the need to analyze the in- The advantage of the classification system is that it tegrity of the vertical and horizontal supports and the need provides a method to determine the type of injury and to focus on these supports for reduction and possible rigid degree of severity based on the site and numbers of but- fixation. It is assumed that proper reduction of the frac- tresses and beams involved with the trauma. Attention tured beams and buttresses will lead to accurate width, can then be focused toward a more direct approach that length, and projection of the facial with a con- is necessary to deal with these problems. The system also comitant correction of appearance and function. Finer is an easy means of communication between diagnosti- details of reconstruction can be maintained by analyz- cians and surgeons who work on these types of cases. ing and correcting for bone displacement, orbital wall and The disadvantages of the classification system is floor involvement, and comminution. Using the present that it is not all-inclusive, negates consider- scheme, the theoretical numbers of unilateral unique frac- ations, and does not describe the status of nasal bones, ture pattern combinations can be determined by the com- the orbital lamina, or, necessarily, the displacement and binations (C)[11, n = 1, 2, 3. . .1] = 2047. Other modifi- comminution of fractures. Such modifers would add

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Table 3. Patient Fracture Pattern Classification Schemes

Current No. of Proposed Classification* Anatomic Sites Classification† Patients Unilateral Midfacial Fracture Patterns V1s Medial 2 V1i Medial maxilla 1 V2s Lateral orbit Zingg type A2 1 V2i Lateral maxilla 3 H1 Superior orbit 3 H1c Frontal glabella 2 H2 Inferior orbit Zingg type A3 6 H2l Zygomatic arch Zingg type A1 5 V1s, H2 Medial/inferior orbit 2 V1i, H2 Inferior orbit, medial maxilla 2 V2s, V2i Lateral orbit, lateral maxilla 3 V2s, H2 Lateral/inferior orbit 3 V2i, H2l Lateral maxilla, zygomatic arch 3 V2s, H2l Lateral orbit, zygomatic arch 1 H2, H2l Inferior orbit, zygomatic arch 1 H1, H1c Superior orbit and glabella 1 V1s, V1i, H2 Medial/inferior orbit, medial maxilla 3 V1s, V2s, V2i Medial/lateral orbit, lateral maxilla 1 V1i, V2i, H2 Medial/lateral maxilla, inferior orbit 1 V2s, V2i, H2 Inferior/lateral orbit, lateral maxilla 4 V2s, V2i, H2l Lateral orbit, lateral maxilla, zygomatic arch 5 V2s, H2, H2l Inferior/lateral orbit, zygomatic arch 1 V2i, H2, H2l Inferior orbit, lateral maxilla, zygomatic arch 3 V1i, V2s, V2i, H2 Inferior/lateral orbit, medial/lateral maxilla 2 V2s, V2i, H2, H2l Inferior/lateral orbit, lateral maxilla, zygomatic arch Zingg type B 29 V2i, V3, H2, H2l Lateral maxilla, pterygoid plate, zygomatic arch 3 V1s, V1i, V2s, H1, H2 Medial/lateral/superior/inferior orbit, medial maxilla 1 V1s, V1i, V2i, H2, H2l Medial/inferior orbit, medial/lateral maxilla, zygomatic arch 1 V1s, V2s, V2i, H2, H2l Medial/lateral/inferior orbit, lateral maxilla, zygomatic arch 2 V1i, V2s, V2i, H2, H2l Lateral/inferior orbit, medial/lateral maxilla, zygomatic arch 8 V1s, V2i, V3, H2, H2l Medial/inferior orbit, lateral maxilla, pterygoid, zygomatic arch 1 V2s, V2i, V3, H2, H2l Lateral/inferior orbit, lateral maxilla, pterygoid, zygomatic arch 1 V2s, V2i, H1, H2, H2l Superior/lateral/inferior orbit, lateral maxilla, zygomatic arch 2 V2s, V2i, H2, H2l, H3 Lateral/inferior orbit, lateral maxilla, alveolus, zygomatic arch 3 V1s, V1i, V2s, V2i, V3, H2 Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid LeFort II (unilateral) 1 V1s, V1i, V2s, V2i, H2, H2l Medial/lateral/inferior orbit, medial maxilla, zygomatic arch 7 V1s, V1i, V2s, V2i, H2, H3 Medial/lateral orbit, medial/lateral maxilla, alveolus 1 V1i, V2s, V2i, H1, H2, H2l Superior/inferior/lateral orbit, medial/lateral maxilla, zygomatic arch 1 V1s, V1i, V2s, V2i, V3, H2, H2l Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, zygomatic arch LeFort III (unilateral) 1 V1s, V1i, V2s, V2i, H2, H2l, H3 Medial/lateral/inferior orbit, medial/lateral maxilla/alveolus, zygomatic arch LeFort III (unilateral) 1 Bilateral Midfacial Fracture Patterns LH2l Zygomatic arch Zingg type A1 RH2l Zygomatic arch Zingg type A1 1 L V2i Medial maxilla RH2l Zygomatic arch Zingg type A1 1 L H2 Inferior orbit Zingg type A3 R V1i, V2i Medial/lateral maxilla 1 L V1s, V1i, V2s, V2i, H2 Medial/lateral/inferior orbit, medial/lateral maxilla R V1i, V2i Medial/lateral maxilla 1 L V1i, V2i Medial/lateral maxilla R V1i, V2i Medial/lateral maxilla 1 L V1s, V1i, V2s, H2 Medial/lateral/inferior orbit, medial maxilla R V1s, V1i, V2s, H2 Medial/lateral/inferior orbit, medial maxilla 1 L V2s, V2i, H2 Lateral/inferior orbit, lateral maxilla R V2s, H1 Superior/lateral orbit 1 L V2s, V2i, H2, H2l Lateral/inferior orbit, lateral maxilla, zygomatic arch Zingg type B R V2s Lateral orbit Zingg type A2 1

(Continued)

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Table 3. Patient Fracture Pattern Classification Schemes (cont)

Current No. of Proposed Classification* Anatomic Sites Classification† Patients LH2l Zygomatic arch Zingg type A2 R V2s, V2i, H2, H2l Lateral/inferior orbit, lateral maxilla, zygomatic arch Zingg type B 1 L V1i, V2s, V2i, H2 Lateral/inferior orbit, medial/lateral maxilla R V2i, H2, H2l Inferior orbit, lateral maxilla, zygomatic arch 2 L H2 Inferior orbit Zingg type A3 R V1i, V2s, V2i, V3, H2, H2l Lateral/inferior orbit, medial/lateral maxilla, pterygoid LeFort I (unilateral) 1 L V1i, V2i, H2 Inferior orbit, medial/lateral maxilla R V1i, V2s, V2i, H2, H2l Lateral/inferior orbit, medial/lateral maxilla, zygomatic arch 1 L V1i, V2i Medial/lateral maxilla R V1i, V2s, V2i, H2, H2l Lateral/inferior orbit, medial/lateral maxilla, zygomatic arch 1 L V1s Medial maxilla R V1s, V2s, H1c Lateral orbit, medial maxilla, glabella 1 L V1s, H1, H1c Superior/medial orbit, glabella R V1s, H1, H1c Superior/medial orbit, glabella 1 L H1c Glabella R V1s, V1i, V2s, V2i, H1, H1c, H2, H2l Superior/medial/lateral/inferior orbit, glabella, medial/lateral maxilla, 1 zygomatic arch L V1s, H1c Medial orbit, glabella R V1s, V1i, V2i, H1c, H2 Medial/inferior orbit, medial maxilla, glabella 1 L H1c Glabella R V1s, V2s, V2i, H1c, H2, H2l Medial/lateral/inferior orbital rim, glabella, lateral maxilla, zygomatic arch 1 L H1, H1c, H2l Superior orbit, glabella, zygomatic arch R V1s, V2s, V2i, H1, H1c, H2 Superior/medial/lateral/inferior orbital rim, glabella, lateral maxilla 1 L H2 Inferior orbit Zingg type A3 R V1i, V2i Medial/lateral maxilla 1 L V1s, V1i, V2s, V2i, H2 Medial/lateral/inferior orbit, medial/lateral maxilla R V1i, V2i Medial/lateral maxilla 1 L V1i, V2i Medial/lateral maxilla R V1i, V2i Medial/lateral maxilla 1 L V1i, V2i, H2 Inferior orbit, medial/lateral maxilla R V1i, V2s, V2i, V3, H2, H2l Lateral/inferior orbit, medial/lateral maxilla, zygomatic arch LeFort I (unilateral) 1 L V1i, V2s, V2i, V3, H2, H2l Lateral/inferior orbit, medial/lateral maxilla, pterygoid, zygomatic arch LeFort III (unilateral) R V1i, V2s, V2i, V3, H2l Lateral orbital rim, medial/lateral maxilla, pterygoid, zygomatic arch LeFort I (unilateral) 1 L V1i, V2i, V3 Medial/lateral maxilla, pterygoid LeFort I (unilateral) R V1i, V2i, V3, H3c Medial/lateral maxilla, pterygoid, prealveolus LeFort I (unilateral) 1 L V1i, V2i, V3, H2l Medial/lateral maxilla, pterygoid, zygomatic arch LeFort I (unilateral) R V1i, V2i, V3, H2, H3, H3c Medial/lateral maxilla, pterygoid, inferior orbit, alveolus/prealveolus LeFort I (unilateral) 1 L V1s, V2s, V2i, H2, H2l Medial/lateral/inferior orbit, lateral maxilla, zygomatic arch R V1s, V2i, H2 Medial/inferior orbit, lateral maxilla 1 L V1s, V1i, V2s, V2i, V3, H2 Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid LeFort II (unilateral) R V1s, V1i, V2i, V3, H2, H2l Medial/inferior orbit, medial/lateral maxilla, pterygoid, zygomatic arch LeFort II (unilateral) 1 L V2s, V2i, V3, H1, H1c, H2 Superior/lateral/inferior orbit, glabella, lateral maxilla, pterygoid R V2i, V3 Lateral maxilla, pterygoid 1 L V1i, V2s, V2i, V3, H2 Lateral/inferior orbit, medial/lateral maxilla, pterygoid LeFort I (unilateral) R V1s, V1i, V2i, V3, H2, H2l, H3 Medial/inferior orbit, medial/lateral maxilla, alveolus, pterygoid, zygomatic LeFort II (unilateral) 1 arch L V1s, V1i, V2s, V2i, V3, H2 Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid LeFort II (unilateral) R V1s, V1i, V2s, V2i, V3, H2 Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid LeFort II (unilateral) 1 L V1s, V1i, V2s, V2i, V3, H2, H3, H3c Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, LeFort II (unilateral) alveolus/premaxilla R V1i, V2i, V3, H2, H2l, H3, H3c Inferior orbit, medial/lateral maxilla, pterygoid, alveolus/prealveolus LeFort II (unilateral) 1 L V1s, V1i, V2s, V2i, V3, H1c, H2 Medial/lateral/inferior orbit, glabella, medial/lateral maxilla, pterygoid LeFort II (unilateral) R V1s, V1i, V2i, H2 Medial/inferior orbit, medial/lateral maxilla, zygomatic arch 1 L V1s, V1i, V2s, V2i, H2, H2l Medial/lateral/inferior orbit, medial/lateral maxilla, zygomatic arch R V1i, V2s, V2i, H2, H2l Lateral/inferior orbit, medial/lateral maxilla, zygomatic arch 1

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Table 3. Patient Fracture Pattern Classification Schemes (cont)

Current No. of Proposed Classification* Anatomic Sites Classification† Patients L V1s, V1i, V2s, V2i, V3, H2, H2l Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, LeFort III (unilateral) zygomatic arch R V1s, V1i, V2i, V3, H2, H2l Medial/inferior orbit, medial/lateral maxilla, pterygoid, zygomatic arch 1 L V1s, V1i, V2s, V2i, V3, H2l Medial/lateral orbit, medial/lateral maxilla, pterygoid, zygomatic arch LeFort III (unilateral) R V1s, V1i, V2s, V2i, V3, H2, H2l, H3c Medial/lateral/inferior orbit, medial/lateral maxilla, prealveolus, LeFort III (unilateral) 1 pterygoid, zygomatic arch L V1s, V1i, 2s, V2i, V3, H1c, H2, H2l, H3c Medial/lateral/inferior orbit, medial/lateral maxilla, glabella, pterygoid, LeFort III (unilateral) prealveolus, zygomatic arch R V1s, V1i, V2s, V2i, V3, H1, H1c, H2, H2l Superior/medial/lateral/inferior orbit, glabella, medial/lateral maxilla, LeFort III (unilateral) 1 pterygoid, zygomatic arch L V1s, V1i, V2s, V2i, V3, H2, H2l Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, LeFort III (unilateral) zygomatic arch R V1s, V1i, V2s, V2i, V3, H2, H2l, H3 Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, alveolus, LeFort III (unilateral) 1 zygomatic arch L V1s, V1i, V2s, V2i, V3, H2, H2l Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, LeFort III (unilateral) zygomatic arch R V1s, V2s, V2i, V3, H2, H2l Medial/lateral/inferior orbit, lateral maxilla, pterygoid, zygomatic arch LeFort III (unilateral) 1 L V1s, V1i, V2s, V2i, V3, H2, H2l, H3 Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, alveolus, LeFort III (unilateral) zygomatic arch R V1s, V1i, V2s, V2i, H2, H2l, H3 Medial/lateral/inferior orbit, medial/lateral maxilla, zygomatic arch, 1 alveolus L V1s, V1i, V2s, V2i, V3, H1c, H2, H2l, Medial/lateral/inferior orbit, glabella, medial/lateral maxilla, pterygoid, LeFort III (unilateral) H3, H3c zygomatic arch, alveolus/prealveolus R V1s, V1i, V3, H1c, H2, H3, H3c Medial/inferior orbit, medial maxilla, pterygoid, glabella, 1 alveolus/prealveolus L V1s, V1i, V2s, V2i, H1c, H2, H2l, H3c Medial/lateral/inferior orbit, glabella, medial/lateral maxilla, zygomatic arch, prealveolus R V1s, V2i, V3, H1c, H2, H3, H3c Medial/inferior orbit, glabella, medial maxilla, pterygoid, LeFort II (unilateral) 1 alveolus/prealveolus L V1s, V1i, V2s, V2i, V3, H2, H2l Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, LeFort III (unilateral) zygomatic arch R V1s, V1i, V2s, V2i, V3, H2, H2l Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, LeFort III (unilateral) 1 zygomatic arch L V1s, V1i, V2s, V2i, V3, H2, H2l Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, LeFort III (unilateral) zygomatic arch R V1i, V2i, V3, H2, H2l Inferior orbit, medial/lateral maxilla, pterygoid, zygomatic arch LeFort I (unilateral) 1 L V1s, V2s, V2i, V3, H1, H2, H2l Superior/medial/lateral/inferior orbit, lateral maxilla, pterygoid, LeFort III (unilateral) zygomatic arch R V1s, V1i, V2s, V2i, H1, H1c, H2, Superior/medial/lateral/inferior orbit, glabella, medial/lateral maxilla, 1 H2l,H3 zygomatic arch, alveolus L V1s, V1i, V2i, V3, H1c, H2 Medial/inferior orbit, medial/lateral maxilla, glabella, pterygoid LeFort II (unilateral) R V1s, V1i, V2s, V2i, V3, H1, H1c, H2, H2l Superior/medial/lateral/inferior orbit, medial/lateral maxilla, glabella, LeFort III (unilateral) 1 pterygoid, zygomatic arch L V1s, V1i, V2s, V2i, V3, H2, H2l Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, LeFort III (unilateral) zygomatic arch R V1s, V1i, V2s, V2i, V3, H2, H2l, H3, H3c Medial/lateral/inferior orbit, medial/lateral maxilla, pterygoid, alveolus/ LeFort III (unilateral) 1 prealveolus, zygomatic arch

*See legend to Figure 1 and Table 1 for an explanation of abbreviations. L indicates left; R, right. †Empty cells indicate that no current classification exists for the correlating “Proposed Classification” and “Anatomic Sites” descriptions.

more information, but at the same time further add to quantitate a variety of patterns and with such methods the complexity of the system. there should be potential application to the analysis treat- The classification system also affords a method of ment outcomes and series in which patients are pro- quantitation as shown by the mock in which vided different treatment modalities. The system thus al- information was communicated from one surgeon to an- lows for a comparison of number and location of sites of other. The methods were easily learned and found to be injury as to their treatment and results. Further investi- extremely accurate in defining the beam and buttress frac- gations, however, will be necessary to evaluate the use- ture patterns. The system provided an opportunity to fulness of this aspect of the classification system.

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Accepted for publication March 24, 1998. Table 4. Mock Fracture Diagrams and Summaries* Corresponding author: Terry L. Donat, MD, Depart- ment of Otolaryngology–Head and Neck Surgery, Wayne Mock No. Fracture Pattern Notation State University, 41935 W 12 Mile Road, Novi, MI 48377. Schematic Diagram to Written Designation Transcription (n = 60) 1 L V1i, V2i, V3i R V1i, V2i, V3i REFERENCES 2 L V2s, V2i, H2, H2l R V1s, H2 1. LeFort R. Etude Experimental sur les fractures de la machoire superieure. Rev 3 L V1s, V2i, V3, H2, H3c Chir Paris. 1901;23:208-227. [Tessier P, trans. Experimental study of fractures R V1i, V2i, V3, H2 of the upper . Plast Reconstr Surg. 1972;50:497-506, 600-607]. 4 L V1s, H1, H1c 2. Rowe NC, Killey H. Fractures of the Facial Skeleton. Baltimore, Md: Williams & R V1s, V1i, H1c, H2 Wilkins; 1955:205-233. 5LH2l,H3 3. Rudderman RH, Mullen RL. of the facial skeleton. Clin Plast Surg. R V1s, V1i, V2i, V3, H2, H2l 1992;19(1):11-29. 4. Manson PN. Some thoughts on classification and treatment of LeFort fractures. Written Designation to Schematic Diagram Transcription (n = 60) Ann Plast Surg. 1986;17:356-363. 6 L V1s, V2s, H1, H1c 5. Markowitz BL, Manson PN. Panfacial fractures: organization of treatment. Clin R V1s, H1, H1c Plast Surg. 1989;16(1):105-113. 7 L V1s, V2s, V2i, V3, H2, H2l 6. Manson PN, Hoopes JE, Su CT. Structural pillars of the facial skeleton: an approach R V1s, V2s, V2i, V3, H2, to the management of LeFort fractures. Plast Reconstr Surg. 1980;66:54-61. H2l 7. Gruss JS, MacKinnon SE. Complex maxillary fractures: the role of buttress fixa- 8 L V1i, V2i, V3 tion and immediate . Plast Reconstr Surg. 1986;78:9-16. R V1i, V2i 8. Gruss JS, Van Wyck L, Phillips JH, et al. The importance of the zygomatic arch 9 L V1i, H3, H3c in complex midfacial fracture repair and posttraumatic orbitozygomatic defor- R V2s, V2i, H2, H2l mities. Plast Reconstr Surg. 1990;85:878-890. 10 L V2s, H1, H2l 9. Stanley RB. Reconstruction of the midfacial vertical dimension following LeFort fractures. Arch Otolaryngol. 1984;110:571-575. *See legend to Figure 1 and Table 1 for an explanation of abbreviations. L 10. Gruss JS. Nasoethmoid orbital fractures: classfication and role of indicates left; R, right. grafting. Plast Reconstr Surg. 1985;75:303-314. 11. Stanley RB. Buttress fixation with plates. Operative Techniques Otolaryngol Head Neck Surg. 1995;6:97-103. CONCLUSIONS 12. Zingg M, Leadrach K, Chen J, et al. Classification and treatment of zygomatic fractures: a review of 1025 cases. J Oral Maxillofac Surg. 1992;50:778-790. The proposed classification system is conceptually in 13. Leipzinger LS, Manson PN. Nasoethmoid orbital fractures: current concepts and anatomic and descriptive accord with the currently management principles. Clin Plast Surg. 1992;19(1):167-193. practiced methods of facial fracture reduction and rigid 14. Manson PN, Shack RP, Leonard LG. Sagittal fractures of the maxilla and palate. fixation. This newly proposed facial fracture classifica- Plast Reconstr Surg. 1983;72:484. 15. Marciani RD. Management of midfacial fractures: fifty years later. J Oral Maxil- tion scheme provides a convenient, succinct, descrip- lofac Surg. 1993;51:960-968. tive, and reproducible method of designating beam and 16. Gruss JS, Bubak PJ, Egbert MA. Craniofacial fractures: an algorithm to optimize buttress fracture patterns. This scheme may be used to results. Clin Plast Surg. 1992;19(1):195-206. accurately communicate and compare, in greater detail 17. Gentry LR, Manor WF, Turski, PA, et al. High resolution CT analysis of facial struts in trauma, II: osseous and soft tissue complications. Am J Radiol. 1983;140:533-541. than permitted using the LeFort or other independent 18. Marsh JL, Vannier MW, Gado M, Stevens WG. In vivo delineation of facial frac- classification schemes, the essential site and degree-of- tures: the application of advanced medical imaging technology. Ann Plast Surg. severity characteristics of facial fractures critical to 1986;17:364-375. their surgical reduction and reconstruction. The use- 19. Manson PN, Markowitz B, Mirvis S, et al. Toward CT-based facial fracture treat- fulness of this classification scheme in determining ment. Plast Reconstr Surg. 1990;85:202-211. 20. Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma. Curr Probl optimal methods of treatment and subsequent out- Diagn Radiol. 1993;22:145-188. comes in dealing with midfacial fracture requires fur- 21. Luce EA. Developing concepts and treatment of complex maxillary fractures. Clin ther investigation. Plast Surg. 1992;19(1):125-131.

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